HomeMy WebLinkAbout840593.tiff AGGREGATE EXCESS RISK INSURANCE AGREEMENT
This Agreement is between THE HARTFORD ACCIDENT AND INDEMNITY COMPANY,
Hartford Plaza, Hartford, Connecticut 06115 and the Employer named in the
Schedule.
SCHEDULE
1. Employer: WELD COUNTY
2. Place of Delivery: Greeley, CO
3. Effective Date: September 15, 1983
4. Loss Definition: (a) (Loss Incurred) (b) (Claims Paid) X
5. Annual Premium: $6,000.00
6. Reimbursement Percentage: 100%
7. Risk Insurance Limit: $1,000,000.00
8. Excess Risk Insurance Determinant Factor: $136.00 per employee
9. Individual Claim Limit: $50,000.00
10. Loss Reporting Period: 1 Month
11. Companion Individual Excess Risk Agreement: X Yes _ No
12. Group Policy(ies): GL-19628
13. Benefits provided by the Plan and covered
by this Agreement: Medical
14. Administrator: James/Galbraith & Green
3895 Upham St. #100
P. 0. Box 987
Wheat Ridge, CO 80033
G-2822 ER-1 T- E15
940593
pE
AGREEMENT
In consideration of the mutual promises contained in this Agreement, it is
agreed as follows:
DEFINITIONS
The following terms, if used in this Agreement, have these meanings:
We, us, or our - The Hartford Accident and Indemnity Company or any of
its subsidiaries or affiliates which it designates to perform the
functions and meet the obligations to which it agrees in this Agreement.
You or your - The Employer named in the Schedule.
The Plan - The employee benefit plan which you have established to
provide benefits to eligible employees and which is attached to and
forms a part of this Agreement. This Agreement covers only those
benefits provided by the Plan that are shown in the Schedule.
Eligible Employees - Employees who are eligible for benefits under the
Plan.
Plan Late Entrant - An employee or dependent who did not become covered
under the Plan until later than 31 days after the first date on which he
or she was eligible to do so.
G-2822 ER-2 E23
DEFINITIONS (Continued)
• Substantive Change in Plan Exposures - Includes, but is not limited to:
(i) a change in Plan benefits;
(ii) addition or deletion of employee units, locations, or associated
companies;
(iii) any increase or decrease in the number of covered employees
which exceeds 15% of the number covered immediately before the
change.
▪ Incurred - A medical expense is incurred on the date the service or
supply giving rise to the expense is provided. With respect to
disability income benefits, if any, a loss is incurred on the date(s) of
disability for which such benefits are due.
• Liability Period - A period of one year, unless terminated in accordance
with the termination provision of this Agreement. The first liability
period shall commence on the effective date shown in the Schedule, and
subsequent liability periods shall commence on January 1 of each year
beginning in 1984.
• Loss — Loss you sustain prior to the termination date of this Agreement
in accordance with the terms, conditions, benefits, limitations and
exclusions of the Plan.
(i) "Loss" shall include the following sub—item (a) or (b) which is
indicated in the Schedule:
(a) (Loss Incurred)
"Loss" shall mean only such amounts of Plan Benefits as are
actually paid for loss incurred by eligible employees on or
after the effective date shown in the Schedule.
(b) (Claims Paid)
"Loss" shall mean only such amounts of Plan Benefits as are
actually paid on or after the effective date shown in the
Schedule.
G-2822 ER-3 T— E33
DEFINITIONS (Continued)
(ii) "Loss" shall not include:
(a) With respect to any individual employee or dependent covered
under the Plan; any amount paid in any liability period, which
is in excess of the Individual Claim Limit, if any, shown in
the Schedule.
(b) Any amount paid to the extent we reimburse you such amount in
accordance with the terms of any INDIVIDUAL EXCESS RISK
INSURANCE AGREEMENT which exists between you and us. See the
Schedule to determine if such an agreement exists.
(c) Any amount paid in benefits to or for a Plan Late Entrant,
unless evidence of such Plan Late Entrant's insurability has
been approved by us or the Administrator.
(d) Any amount which is not payable according to the terms of the
Plan.
(e) Any court costs or interest upon judgements.
(f) Any investigation, legal, or claim adjustment expenses.
(g) Any punitive or exemplary damages.
(h) Any salaries paid to your employees or fees paid to an
Administrator.
G-2822 ER-4 E44
I. YOUR DUTIES
a. You agree to pay us the Annual Premium shown in the Schedule or as
amended in accordance with Section IV of this Agreement. The First
Annual Premium is due on the effective date shown in the Schedule.
Subsequent annual premiums shall be due on January 1 of each year
beginning 1984. Each Annual Premium shall be payable no later than
31 days after the date it is due.
b. You agree to furnish us, within 31 days following the end of each
Loss Reporting Period indicated in the Schedule, an Experience Report
satisfactory to us. The Experience Report will show in detail the
amounts of Plan benefits paid during the Loss Reporting Period. An
Experience Report shall include, but is not limited to, the following
items with respect to all checks or drafts issued in settlement of
claims under the Plan:
(i) The Claimants' Names;
(ii) The date of issue of each check or draft;
(iii) The amount of each check or draft;
(iv) The specific types of benefits paid, for each check or draft
that was issued. The types of benefits provided by the Plan
and covered by this Agreement are shown in the Schedule.
G-2822 ER-5 T- E53
I. YOUR DUTIES (Continued)
The Experience Report must also include:
. The number of employees with and without dependents covered under
each applicable benefit type shown in Item I.b. (iv), above, as of
the first day of the Loss Reporting Period covered by the report;
and
. the number of claims which, as of the last day of the Loss
Reporting Period covered by the Report, had been received but not
yet paid.
c. You agree that Plan benefits will be paid within 60 days after
receiving such due proof as is required by the Plan.
d. You agree to be responsible for the investigation, settlement, or
defense of any claim made, suit brought, or proceeding instituted
against you. We have the right, at our option and expense, to
participate with you in the defense or appeal of any action, suit, or
proceeding in which we may, in our judgement, become involved.
e. You agree that we may inspect your books, records, and other data
pertaining to the Plan at any reasonable time or times.
f. You agree to submit to us in writing and reasonably in advance of its
effective date, any proposed substantive change in the exposures
under the Plan. Based upon the effect such change may have upon our
liability, we may change the terms of this Agreement.
G-2822 ER-6 E62
II. OUR DUTIES
a. We agree, in consideration of premium paid, to reimburse you for
loss, as defined, to the extent such loss, during any one liability
period, exceeds the Annualized Deductible Amount determined from the
following steps:
STEP I For each calendar month during the Liability Period,
multiply the number of employees covered under the Plan on the
15th day of the month times the Excess Risk Insurance Determinant
Factor as shown in the Schedule or as amended in accordance with
Section IV. of this Agreement. (In no event shall the number of
employees used in this calculation for any month be less than 85%
of the number covered on the later to occur of the effective date
or the last preceding anniversary date of this Agreement. )
STEP II. Add the products of each multiplication in STEP I.
Our reimbursement to you shall:
(i) Be paid at the percentage shown in the Schedule.
(ii) Not exceed, in any one Liability Period, the Risk Insurance Limit
shown in the Schedule.
(iii) Be made within 31 days after the date the proper amount is
computed.
b. We reserve the right to determine whether Plan benefit payments which
affect our liability are based on reasonable and customary charges
for necessary services and supplies. Benefits paid for unnecessary
services and supplies and for charges in excess of reasonable and
G-2822 ER-7 T- E71
II. OUR DUTIES (Continued)
customary shall not count toward any Annualized Deductible Amount.
III. TERMINATION OF AGREEMENT
a. Either you or we may terminate this Agreement as of any anniversary
date by giving the other party at least 60 days' advance written
notice of termination.
b. This Agreement will automatically terminate as of the earliest to
occur of:
1. The date you discontinue or modify the Plan without our advance
written consent; or
2. the date you discontinue any of The Hartford Life and Accident
Insurance Company group insurance policy(ies) identified in the
Schedule as the Group Policy(ies); or
3. the date it is determined that you have failed, without good and
sufficient cause, to perform in good faith any of your duties or
obligations under this Agreement; or
4. the end of the period for which premium has been paid; or
5. the date the Administrator designated in the Schedule is no longer
processing claims; unless we have, prior to the date of a change
in Administrator, agreed in writing to such change.
c. We have no obligation to reimburse you for any Plan Benefits which
are paid after the date on which this Agreement terminates.
G-2822 ER-8 E83
IV. MODIFICATION OF AGREEMENT
a. This Agreement may be modified at any time if you and we agree in
writing to the modification.
b. We may change the Annual Premium and/or the Excess Risk Insurance
Determinant Factor shown in the Schedule as of the effective date of
any Substantive Change in Plan Exposures.
c. We may change the Annual Premium and/or the Excess Risk Insurance
Determinant Factor after giving you 90 days' advance written notice
of our intent to do so. Such written notice will be mailed to your
address as last shown on our records and will supersede the
applicable Item(s) of the Schedule and any prior such written
notice(s). However, we may not make such a change according to the
terms of this sub—paragraph IV.c. sooner than the first anniversary
date of this Agreement.
V. DISCLAIMER
a. We act merely as a provider of service to your Plan. We are not a
fiduciary. We do not assume any obligation to perform any of the
functions or provide any of the reports required by the Employee
Retirement Income Security Act of 1974, as amended from time to time.
b. If you have misrepresented any fact to us which was material to our
entering into this Agreement, we may, upon discovery of such
misrepresentation, rescind this Agreement as of its effective date.
G-2822 ER-9 E91
V. DISCLAIMER (Continued)
c. This Agreement is not in place of and does not affect any requirement
to provide Workers' Compensation Insurance.
d. No assignment of your interest under this Agreement shall be binding
on us. Our sole liability shall be to you. We have no obligation to
any other party.
e. The risk insurance provided by this Agreement shall be excess over
other valid and collectable excess insurance, risk insurance,
indemnity against loss or similar coverage by whatever name called.
f. Our entire obligation is set forth in this Agreement. Any obligation
to provide reimbursement for any benefit other than as set forth here
is expressly disclaimed.
g. Even though you have designated an Administrator to perform claims
administration and reporting functions for you, you remain wholly
responsible for everything to which you agree in this Agreement. The
Hartford assumes no responsibility for the acts of the Administrator
and will limit its consideration to benefit payments which are
consistent with the provisions of the Plan.
G-2822 ER-10 E104
This Agreement is made binding by the signatures of your and our
representatives who are authorized to enter into such agreements.
FOR YOU: I 1/02-772/P771/02-772/P77 (1/flit 4S/»'1 , a Ne-/ rn 'Rime ui n l "irr
(Name) (Title)
of WELD COUNTY agree on
(Employer Name) /�
its behalf to the terms f of this Agreement. � �� '
Q�k
ac_f ci,
(Signature) V (Witpa Si to e)
� � �� _,P lei o
LI L (Date)
FOR US: I Robert J. Flanigan , a Secretary
(Name) (Title)
of HARTFORD ACCIDENT AND INDEMNITY COMPANY agree on its behalf to the terms of
this Agreement.
edir • ilizezor 8„,a5tei,
(Signa ) (Witness Signature)
/27a.t-c4. /'I/ /WV /ljd z.C / y /9917
(Date) / (Date)
6-2822 ER-11 T- Elll
WELD COUNTY EMPLOYEE BENEFIT FUND
Effective: January 1, 1983
f
TABLE OF CONTENTS
Page
PARTIES TO THE AGREEMENT i
STOP LOSS INSURANCE COMPANY
EFFECTIVE DATE
SUMMARY OF BENEFITS 1
DEFINITIONS 4
SUPPLEMENTAL ACCIDENT BENEFIT 12
MAJOR MEDICAL BENEFIT 13
HOSPITAL CARE BENEFIT 16
ANESTHESIOLOGY BENEFIT 17
SURGICAL BENEFIT 18
GENERAL LIMITATIONS 19
HOW TO FILE A CLAIM 22
COORDINATION OF BENEFITS 23
MISCELLANEOUS DEFINITIONS 25
COMMON LAW SPOUSE 27
FACILITY OF PAYMENT 27
PROCESS IN CASE OF DISPUTED CLAIM 28
CONVERSION PRIVILEGE 29
SIGNATURE PAGE 30
WELD COUNTY EMPLOYEE BENEFIT FUND
Weld County has adopted the Weld County Employee Benefit Fund (the
"Plan" ) , as herein stated. Weld County agrees to provide for its eligible
employees , during continuance of the Plan , the benefits hereinafter described in
the event such employees incur a disability or they and/or their eligible
dependent(s) incur medical expenses covered by the Plan.
The Plan, designed for the exclusive benefit of eligible Weld County
Employees , is subject to all terms, provisions and conditions recited in the
following pages.
In addition to the benefits hereinafter set forth, insurance policies
have been purchased and are part of the Plan to insure against certain hazards
and to provide for certain contingencies as follows:
1. An Aggregate Stop-Loss policy to insure maximum annual claim
liabilities;
2. A Specific (Individual ) Stop-Loss policy to insure individual
claims in excess of the amount specified in the insurance
contract.
3. A Health Conversion provision to allow an individual to convert to
an individual Medical Policy upon termination.
Copies of the actual policy or policies are available for review at
the offices of Weld County, or James Benefits , the Contract Administrator, and
will be made available, upon request, at a reasonable charge.
Weld County has caused this Plan to be EFFECTIVE as of 12:01 a.m. ,
January 1, 1983, at Greeley, Colorado.
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SUMMARY OF BENEFITS
FOR EMPLOYEES AND DEPENDENTS
Supplemental Accident Benefit: 100% of the first $500.00 per accident ,
per person , not subject to the $100.00
deductible.
Pre-Admission Testing: Covered at 100% of Usual , Reasonable and
Customary medically necessary expenses.
Birthing Centers : Covered at 100% of Usual , Reasonable and
Customary medically necessary expenses.
Major Medical Benefit:
Maximum Lifetime Benefit: $1,000,000 each Covered Person.
Deductible: $100.00 per person each Calendar Year,
not to exceed $200.00 combined
(aggregate) per family each Calendar
Year.
NOTE: The Family Deductible may be
comprised of any combination of eligible
medical expenses among covered family
members.
Co-Insurance: After the deductible has been met, 80% of
the next $2,000 (80% of $4,000 per
family) , and 100% thereafter of Covered
Expenses will be paid per Covered Person
each Calendar Year, but not to exceed the
maximum lifetime benefit. Room and board
charges shall not exceed the
semiprivate, ICU and CCU room rates. All
charges are subject to the "General —
Limitations" of this Plan.
In-Hospital "Well Baby" Hospital Nursery charges and one
Benefit : Physician visit covered as any other
illness subject to the deductible and
coinsurance.
Outpatient Pediatric "Well Pediatric well baby care is available
Baby" Benefit : until the child ' s second birthday;
limited to a maximum of $90 per dependent
child per Calendar Year. This "well
baby" care includes lab and x-ray ser-
vices. Routine immunizations are
available until the child ' s second birth-
. -1-
L
day, not limited to the Calendar Year
maximum.
r Treatment of Alcoholism, Drug Abuse ,
Nervous and Mental Illness :
In-Hospital : 45 days maximum per Calendar Year.
NOTE: Partial hospitilization - the
lesser of 1) the number of days of
patient hospitilization or 2) 90 days in
any Calendar Year. (Each two partial
days will count as one full hospital
day. )
Out-patient: 50% of each visit, not to exceed usual ,
reasonable and customary, up to a maximum
payment of $1,250.00 per Calendar Year.
The eligible charges for outpatient ser-
vices are the reasonable charges for the
care and treatment of mental , psycho-
neurotic and personality disorders fur-
nished (1) by a hospital (other than
inpatient or partial hospitalization
services) ; (2) by a Physician ; (3) under
the direct supervision of a Physician by
a comprehensive health care service cor-
poration , a community mental health
center, or other mental health clinic,
which is licensed or approved to furnish
mental health services by the state where
rendered; or (4) by a social worker
registered or licensed by the state where
rendered , if furnished under the direct
supervision of a Physician.
Chiropractic: $30.00 maximum consideration per visit.
$500.00 maximum payment per Calendar
Year.
$5,000.00 maximum payment per lifetime
for each Covered Person.
Covered Expenses (Up to Usual ,
Customary and Reasonable) Examples
A. Doctor' s services.
B. Prescription drugs.
C. Blood and blood plasma.
D. Ambulance service.
E. Artificial limbs.
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•
F. Rental of wheel chairs , braces ,
crutches , etc.
G. Physical therapy and outpatient oxy-
gen therapy.
H. Intensive care unit room charges.
I. Emergency room services.
J. Hospital room and board.
NOTE: This is a partial listing of
covered major medicaTxpenses. Items
specifically excluded are shown elsewhere
in the Plan.
C
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DEFINITIONS
Terms as used herein shall be deemed to define terms that may be used in the
/— wording of the Plan Document. These definitions shall not be construed to ora-
1 vide coverage under any benefit unless specifically provided.
A. GENERAL DEFINITIONS
1. Age Discrimination - Subject to any changes in the Social Security Act ,
1T active employees age 65 and over (up to 70 years of age) are
entitled to the same and/or equal benefits that they had prior to age
65.
2. Amendment is a formal document changing the provisions of the Plan and
signed by the representatives of Weld County. Amendments apply to all
Covered Persons , including those persons who are covered before the
Amendment becomes effective, unless otherwise specified.
3. Common-Law Marriages - In order for an employee of Weld County to be
eligible for dependent medical coverage, the Common-Law Marriage must be
recognized by the State of Colorado. (See page 27. )
4. Calendar Year is the 12 month period beginning on each January 1st and
ending on the following December 31st.
5. Contract Administrator shall mean the person or firm employed by the
Plan Administrator who is responsible for the processing of claims and
payment of benefits , administration , accounts, reporting and other ser-
fvices contracted for by Weld County.
6. Plan Year is the 12 month period beginning on each January 1st and
ending the following December 31st.
7. Employer shall refer to Weld County.
8. Medicare - Title XVIII (Health Insurance for the Aged) of the United
States Social Security Act as amended.
9. Plan shall refer to the benefits and provisions as described herein for
payment.
10. Plan Administrator - Weld County.
11. Subrogation - The transfer of one' s liabilities for another's ; in this
case the temporary assumption of the claimant 's liabilities by the Plan
prior to repayment by the party of primary liability. This Plan con-
tains a subrogation clause and the Claimant is obligated to obtain any
monies available from third parties to reduce the Plan ' s claim losses.
-4-
B. MEDICAL DEFINITIONS
1. Expense incurred means only the fees and prices regularly and custo-
manly charged tor the medical services and supplies generally furnished
for cases of comparable nature and severity in the particular geographi -
cal area concerned. Any agreement as to fees or charges made between
the individual and the Physician shall not bind the Plan Administrator
in determining its liability with respect to expense incurred. Expense
incurred is deemed to be incurred on the date on which the service or
supply is rendered or obtained.
2. Illness shall mean bodily sickness or disease , psychiatric disorders ,
and,in the case of a newborn child , congenital abnormalities.
Illness must be medically diagnosed and be treated by a Physician for
purposes of determining benefits payable.
3. Morbid Obesity shall mean a condition in which the pressure of excess
weight causes physical trauma; or where pulmonary and circulatory insuf-
ficiencies are present; or where complications related to the treatment
of conditions such as arteriosclerosis, diabetes or coronary disease
exist ; and where the person is 100% or 100 pounds overweight , whichever
is greater, according to the Metropolitan Life Table of Desirable
Weights. (Excerpt from The Four Steps to Weight Control . )
4. Injury is a condition which results independently of sickness and all
other-causes and is a result of an externally violent force , or acci -
dent.
5. HIAA Prevailing Charge Study is The Health Insurance Association of
America Schedule and shall—be the basis for dental claim reimbursement
at "Usual , Reasonable and Customary" levels , applied to the particular
Zip-code area where the procedure is performed.
6. Pregnancy includes (1) all pregnancies except extra-uterine , which are
considered to be genito-urinary conditions , (2) childbirth , (3) mis-
carriage , or (4) any complications arising wholly from these conditions ,
and (5) any pregnancy complications arising from any trauma, and (6)
only those charges related to the pregnancy of a female employee or
spouse of an enrolled employee.
7. Period of Disability for a Covered Employee as it applies to an indivi -
dual , means all periods of disability arising from the same cause ,
including any and all complications therefrom except that if the indivi -
dual completely recovers or returns to active full -time employment , any
subsequent period of disability from the same cause shall be considered
a new disability.
For a Covered Dependent , the term "Period of Disability," means all
periods of disability arising from the same cause including any and all
complications therefrom, except that if the dependent re-covers for a
period of three months and throughout such period is capable of resuming
( -5-
the normal activities of a person in good health and of the same age and
sex , any subsequent period of disability from the same cause shall be
considered a new period of disability.
8. Total Disability shall mean that the Covered Employee is prevented ,
TEFFry because of a non-occupational injury or non-occupational
disease, from engaging in the employee's regular or customary occupation
and is performing no work of any kind for compensation or profit , or if
a Covered Dependent is prevented, solely because of a non-occupational
injury or non-occupational disease , from engaging in all of the normal
activities of a person of like age and sex in good hearth.
C. PROVIDER DEFINITIONS
1. Alcoholism Treatment Center - Any public or private place or other
facility which is licensed by the State to provide alcoholism treatment
services as a detoxification facility and/or inpatient rehabilitation
facility.
2. Hospital means only an institution constituted and operated pursuant to
awT ,engaged in providing on an inpatient basis at the patient 's
expense, diagnostic and therapeutic facilities for the surgical and
medical diagnosis , treatment and care of injured and sick individuals ,
by or under the supervision of a licensed Physician ; and providing
24-hour-a-day services by registered nurses. The term "Hospital " shall
not include an institutional part thereof which is other than inciden-
tally a place for rest , a place for the aged, or a place for con-
valescant care. However, an institution specializing in the care and
treatment of mentally ill patients which would qualify under this defi -
nition as a hospital , except solely for the fact that it lacks organized
facilities on its premises for major surgery, shall nevertheless be
deemed a hospital under the Plan.
In-Hospital Convalescent Care Limitations:
a. Convalescent Care benefits are limited to the normal Convalescent
Care received by the Covered Person while the Covered Person is an
in-patient in the hospital for treatment of a specific acute medi -
cal , surgical , or psychiatric condition ; however ,
b. Convalescent Care is not a benefit when the Covered Person 's
admission to the hospital is for Convalescent Care , or when such
inpatient care ceases to be medically necessary.
c. If a Covered Person remains in the hospital after the date that the
Covered Person 's physician or other health care provider determines
that in-patient hospital care is no longer necessary, then the
Covered Person shall be liable for payment of any physician ' s or
other health care provider' s charges after that date.
3. Intensive Care Unit is a section , ward , or wing within a hospital which
is operated exclusively for critically ill patients and provides special
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supplies , equipment and constant observation and care by registered grad-
uate nurses or other highly trained personnel , excluding , however, any
hospital facility maintained for the purpose of providing normal post-
f operative recovery treatment or service.
4. Nurse shall mean a Registered Graduate Nurse (R.N. ) , a Licensed
Vocational Nurse (L.V. N. ) , or a Licensed Practical Nurse (L.P. N. ).
5. Outpatient is a Covered Person treated at a hospital and confined
less than 15 consecutive hours or treated outside a hospital setting.
6. Physician is a person acting within the scope of his/her license and
holding the degree of Doctor of Medicine (M.D. ) , Doctor of Ostheopathy
(D.0. ) , Doctor of Dental Surgery (D.D.S. ) , Doctor of Medical Dentistry
(D.M. D. ) Doctor of Podiatry (D.P.M. ) , a Board Certified Psychologist
(PhD) , a Doctor of Chiropractic (D.C. ) , Physicians Assistant or Nurse
Practitioner , who is legally entitled to practice medicine in all its
branches under the laws of the State or jurisdiction where the services
are rendered.
7. Semi -Private is a hospital room containing two (2) or more beds, but,
benefits provided therefor do not include any charge made by the hospi -
tal for Intensive Care.
8. Usual , Reasonable and Customary:
a. The usual charge is the most consistent charge by a physician or
provider of service to patients for a given service.
b. The charge is customary when it is within the range of usual charges
for a given service billed by most physicians or providers of ser-
vice with similar training and experience.
c. A charge is reasonable when it meets the usual and customary cri -
teria as detennined oy the Contract Administrator; or it may be
reasonable if, upon review, it merits special consideration based on
the nature and extent of treatment of the particular case.
9. Medically Necessary: Any service or supply for diagnosis or treatment
that is :
a. consistent with the illness, injury or condition of the Covered
Person ; and
b. ordered by an attending Physician ; and
c. in accordance with approved and generally accepted medical or surgi -
cal practice prevailing in the geographical locality where and at
the time when the service or supply is ordered. Determination of
"generally accepted practice" is the perogative of the Contract
Administrator through consultation with appropriate authoritative
medical or surgical persons.
-7-
10. Diagnostic Charges means the actual cost charged for X-Ray or
Laboratory examinations of the Covered Person which are made or recom-
mended by a Physician for diagnostic purposes.
11. Covered Expense includes only those usual , reasonable, and customary
charges made for medical services and supplies which most physicians
would consider to be necessary for treatment of an injury or illness.
D. PARTICIPATION DEFINITIONS
1. Active Service - An employee will be considered in Active Service with
thep oy� er on a day which is one of the employer's scheduled work days
if the employee is performing in the customary manner all of the regular
employment duties with the employer on a full -time basis on that day,
either at one of the employer's business establishments or at some loca-
tion to which the employer's business requires travel . An employee will
be considered in Active Service on a day which is not one of the
employer' s scheduled work days only if the employee was performing in
the customary manner all of the regular employment duties on the pre-
ceding scheduled work day.
A Dependent will be considered in Active Service on any day if the
dependent is then engaging in all the normal activities of a person in
good health of the same age and sex, and is not confined in a medical
facility. (This does not apply to a newborn ).
2. Contribution shall mean the amount payable by the employer or the amount
payable by the employer/employee jointly for participation in the bene-
1 fits of the Plan.
k_
3. Covered Dependents shall be those who are eligible as provided herein
and enrolled by a Covered Employee. Covered Dependents shall be the
spouse of the Covered Employee ; and children from birth to age 19, to
age 23, if a registered student at an accredited college , vocational
school , or university on a full -time basis , provided such children are
unmarried , and dependent upon the Covered Employee for support and main-
tenance. The term "children" shall include natural children , adopted
children , foster children , and step children who depend upon the
employee for support and maintenance.
No employee will be considered both as a dependent and as an employee.
If an employee and spouse are both eligible employees , only one may have
dependent coverage for eligible children.
Covered Dependent shall also include a dependent child after age 19,
provided the child is (1) incapable of self-sustaining employment by
reason of mental or physical handicap, (2) chiefly dependent upon the
Covered Employee and/or the Covered Employee ' s Spouse for support and
maintenance, and (3) has been continuously covered by the Plan prior to
his/her 19th birthday.
Proof of such incapacity and dependency must be furnished to the
Administrator by the Covered Employee within the thirty one (31) days
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prior to the child' s 19th birthday and at reasonable intervals
thereafter.
ir Dependents DO NOT include children of a dependent son or daughter.
4. Covered Employee is a permanent full -time employee of the Employer who
is eligible hereunder and who has been enrolled in the Plan. To be con-
sidered a full -time employee, one must work an average of 32 hours per
week. In addition, such an employee will not be covered unless on the
"date of eligibility" the employee is actually working a full day on
that date ; otherwise , his/her effective date will be deferred until
return to actual service for a full day's work.
5. Covered Person is a Covered Employee or a Covered Dependent.
6. Eligibility and Effective Dates - Employees who are eligible for health
coverage are—rose full -time employees of Weld County. Full -time
employees are those employed in a permanent position scheduled to work,
32 or more hours per week. Coverage shall become effective on the first
day of the month following the first full month's pay period.
All employees shall become covered as they become eligible subject to
the following :
a. All enrollments are subject to making proper application for
coverage under the Plan.
b. Dependents shall be covered simultaneously with employees covering
them as dependents, provided they are not confined in a hospital on
the effective date. Coverage for newborn children will begin from
birth. However, they need to be formally enrolled and appropriate
coverage arranged within thirty-one (31) days from birth for
coverage to be effective thereafter.
c. For dependents (as stated in a and b above) who are not enrolled
within this thirty-one (31) day period, and for whom coverage is
subsequently desired, a health questionnaire showing evidence of
insurability will be required. Coverage will begin on the date of
approval of the Contract Administrator.
d. An open-enrollment period will be scheduled in November of each
year.
7. Pre-existing Conditions
New Employees or Covered Persons becoming eligible after January 1, 1983
will not be entitled to covered medical expenses that are incurred as
the result of an injury or sickness for which the Covered Person has
consulted with a Physician or received any medical care or services
within the three month period immediately preceding the effective date
of coverage , unless incurred after the expiration of a period of:
-9-
a. Three (3) consecutive months ending after the date the benefits are
effective for the Covered Person during which no medical care or
treatment of such injury or illness has been received, or
b. After a period of six (6) consecutive months during which the
Covered Person was continuously at work and a member of the plan.
(This does not pertain to Covered Dependents) ,or
c. After a period of twelve (12) consecutive months during which the
Covered Person has been continuously a member of the Plan.
8. Individual Termination of Coverage:
Coverage for Covered Emproyees and/or Covered Dependents will terminate
on the earliest of the following dates :
a. The date of termination of the Plan.
b. The date the Covered Person becomes a full -time member of the
Armed Forces of any country.
c. The date the Covered Person ceases to meet eligibility requirements.
d. The end of the month when contributions cease.
9. Late Entrants - Employees or dependents not enrolled within thirty-one
IST.7 days following their eligibility date , or , in the case of newly
acquired dependents, within thirty-one (31) days of such acquisition ,
must provide evidence of good health satisfactory to the Contract
Administrator. Coverage will begin on the date of approval by the
Contract Administrator.
An open enrollment will be conducted each year during the month of
November. Enrollment during this month will not require evidence of
good health.
10. Personal Leave of Absence - Properly enrolled employees of the Employer
may continue, at their expense, health coverage for themselves and/or
their dependents while on an approved Personal Leave of Absence for the
period indicated by the Employer' s personnel policy.
11. Medical Leave of Absence - When a Physician requires that a Covered
Person not return to work, benefits will be continued for a period not
to exceed the length of time accrued under said employee's sick leave
plan , or grants of sick days from the Weld County Sick Leave Bank, plus
31 days , provided the Covered Person makes the required contribution to
the plan which he/she would otherwise be required to contribute. In
order to be covered while on a Medical Leave of Absence, the employee
must be :
a. continuously and totally disabled , and
b. under the care of a licensed Physician , and
-10-
c. provide proof of disability satisfactory to the Employer at reaso-
nable intervals upon request.
12. Dependents of Deceased Employees - Limited coverage for Covered
Dependents of a deceased employee can be continued provided application
for conversion is made in writing to the Plan within thirty-one (31)
days of the date of termination of benefits under this Plan.
E. CONTRIBUTIONS
The employer and employee share in the cost of the benefits under this plan.
ci
-11-
SUPPLEMENTAL ACCIDENT BENEFIT
A. BENEFIT PROVISION
fr
If a Covered Person shall , as a result of accidental bodily injuries
sustained while covered under this Plan , incur expense which is usual ,
reasonable and customary for:
(1) medical treatment or services performed by a legally qualified Phy-
sician ; or
(2) room and board and any other necessary medical services and care pro-
vided by a legally constituted hospital ; or
(3) nursing care provided by a registered graduate nurse ; or
(4) ambulance charges;
the Plan will pay for such related medical expense incurred during the
ninety day period immediately following the date of the accident , but not to
exceed , in the aggregate , for any one accident , the maximum payment spe-
cified in the "Summary of Benefits."
B. LIMITATIONS
1. No payment shall be made under this benefit for expenses incurred for or
on account of pregnancy; or
2. for expenses incurred for eye refractions , eye glasses , hearing aids,
prosthetic devices or fitting of same; or
3. for expenses beyond the limitations described under "General
Limitations" ;
4. nor shall payments under the Supplemental Accident Benefit serve to
satisfy the major medical deductible.
-12-
MAJOR MEDICAL BENEFIT
A. BENEFIT PROVISION
ir
Upon receipt of due proof, satisfactory to the Contract Administrator, that
a Covered Person has incurred an expense for treatment of an illness or
injury, the Plan will pay those amounts indicated in the "Summary of
Benefits" of Medically Necessary Usual , Reasonable, and Customary charges.
The benefits payable shall not exceed the "Maximum Lifetime Benefit" and are
subject to the "Deductible" specified herein and are subject to all limita-
tions and conditions of the Plan.
B. DEDUCTIBLE
1. The "Deductible" equals the sum of the cash deductible specified in the
"Summary of Benefits" and any other provision of this Plan. The deduc-
tible amount applies during each Calendar Year.
2. Carry-over Provision: In order that a Deductible will not be applied
late in one Calendar Year and soon again in the following year , any
Covered Expenses incurred during the last three months of a Calendar
Year which apply toward the Deductible (whether or not it is fully
satisfied) for that year , may also be applied toward the Deductible for
the subsequent Calendar Year.
3. Family Deductible: When the covered members of a family have satisfied
the maximum Deductible per family in a Calendar Year , no further cash
Deductible need be satisfied in that Calendar Year. This applies only
1- to expenses incurred during the Calendar Year; expenses which are
carried over from a prior year under the carry-over provision of this
section will not be recognized.
4. Common Accident: If two or more Covered Persons in the same family are
injured in a common accident , the Deductible amount applicable in the
Calendar Year of the common accident shall be limited to a single cash
Deductible amount for that Calendar Year.
C. MAXIMUM LIFETIME BENEFIT
The Maximum Lifetime Benefit as shown in the "Summary of Benefits" , is the
maximum lifetime amount of benefits available for any Covered Person ,
whether or not there has been an interruption in the continuity of coverage.
D. COVERED MEDICAL EXPENSES
Covered Medical Expenses shall include , subject to the "General
Limitations ," only Medically Necessary Usual , Reasonable and Customary
charges for services and supplies which are incurred by a Covered Person due
to:
1. hospital charges by a "hospital " as defined herein for room and board
and other hospital services required for purposes of treatment , but not
-13-
•
to exceed the average semi -private room rate or intensive care unit room
rate ;
2. charges for anesthetics and their administration ;
3. charges made by a "Physician" or recommended by and directly supervised
by a "Physician" for Medically Necessary services ;
4. charges made for the necessary professional services of a physiothera-
pist ;
5. charges for speech therapy by a qualified speech therapist to restore
speech loss, or correct an impairment, due to (a) a congenital defect
for which corrective surgery has been performed, or (b) an injury or
sickness except for a mental , psychoneurotic or personality disorders ;
6. charges for the following medical services or supplies that are recom-
mended by the Physician :
a. drugs and medicines requiring a Physician 's prescription ;
b. oxygen and/or rental of equipment required for its administration ,
but not to exceed the purchase price of such equipment ;
c. radiotherapy;
d. diagnostic X-ray and laboratory services ;
e. charges for braces , casts , splints , initial artificial limbs or
other original prosthetic appliances to replace lost physical organs
or parts or to aid in their functions when impaired if the loss or
impaired function occurred while covered under this Plan. Covered
charges are for original placement.
f. blood and blood plasma;
g. ambulance to a local hospital where adequate medical treatment
can be administered ;
h. insulin and insulin syringes ;
i , head halter or other traction apparatus ;
j . rental of a wheel chair, special hospital bed , iron lung , crutches ,
and other reasonable , Medically Necessary mechanical and therapeutic
equipment but not to exceed their purchase price ;
k. emergency room services ;
7. charges for pre and post natal visits ;
8. charges for vasectomies and tubal ligations ;
-14-
9. Charges made by a legally qualified Physician for performing oral
surgery consisting of cutting procedures for removal of tumors , cysts ,
and charges incurred to restore sound natural teeth within six months
after the date of an accident, unless medically indicated that treatment
be delayed, provided that the injury or condition and treatment thereof
occurs while this coverage is in effect. Such charges includes dental
X-rays and general anesthesia , Medically Necessary and prescribed by a
legally qualified Physician ;
10. Chiropractic services rendered by a D.C. will only be covered for the
detection and correction by manual or mechanical means , including X-rays
incidental thereto, the structural imbalance , distortion or subluxation
in the human body for the removal of nerve interference , where such
interference is the result of or related to distortion , misalignment , or
subluxation of or in the vertebral column. Chiropractic care which
exceeds the following guidelines may not be considered as a covered
expense if it is determined to be maintenance , palative, or excessive
care:
a. three visits per week for the first four weeks ;
b. two visits per week for the next eight weeks ;
c. one visit per week for the next four weeks ;
Consideration of treatment programs exceeding these guidelines must be
accompanied by the attending Chiropractor' s statement outlining their
Medical Necessity;
The benefits payable under this provision will not exceed the following
maximums:
a. $30. 00 maximum consideration per visit ;
b. $500.00 maximum payment per Calendar Year per Covered Person ;
c. $5,000.00 maximum payment per lifetime per Covered Person.
11. charges for services of a registered graduate nurse or licensed prac-
tical nurse or nurse practitioner , if authorized by a Physician ;
12. charges for allergy testing or injections.
-15-
HOSPITAL CARE BENEFIT
Upon receipt of due proof of eligibility that a Covered Person has incurred
necessary expenses which are reconanended and approved by a "Physician" as herein
defined , for hospital care for diagnosis or treatment of an illness or injury,
the Plan will pay Usual , Reasonable and Customary charges not exceeding the
maximum amount specified in the Summary of Benefits for such charges.
A. DEDUCTIBLE
The "Deductible" equals the sum of the Cash Deductible specified in the
"Summary of Benefits" and any other provision of this Plan. The Deductible
amount applies during each Calendar Year.
B. ROOM, BOARD, AND GENERAL NURSING CARE
The Plan will pay the amount charged by the hospital for a Covered Person
who is confined for room, board, and general nursing care , not to exceed the
Semi-Private , Intensive Care Unit , or Coronary Care Unit room rate.
C. OTHER HOSPITAL CHARGES
The Plan will pay the Usual , Reasonable and Customary amounts charged by the
hospital for Medically Necessary services , medicines , and supplies for
diagnosis or treatment of illness or injury during any one period of con-
finement provided:
1. the Covered Person is hospital -confined as an inpatient ; or
2. the Covered Person has surgery performed in the hospital .
D. SUCCESSIVE PERIODS OF HOSPITAL CONFINEMENT
Successive periods of hospital confinement shall be considered as one con-
finement unless :
1. The later confinement commences after complete recovery from the
sickness or injury which caused an earlier confinement ;
2. The later confinement results from causes entirely unrelated to the
causes of an earlier confinement;
3. The confinements are separated by the employee ' s return to work for two
weeks , or in the case of a dependent , a separation from the previous
confinement of three (3) months duration.
-16-
ANESTHESIOLOGY BENEFIT
A. BENEFIT PROVISION
Benefits are payable when a Covered Person incurs charges for anesthetic
services rendered by a licensed anesthesiologist in connection with a surgi-
cal operation. Under this benefit , the 1974 Anerican Society of
Anesthesiologists Relative Value Guide will be used based on unit value plus
time, but not to exceed the Usual , Customary and Reasonable charge.
B. ANESTHESIOLOGY BENEFIT LIMITATIONS
No amount will be payable under this Section for charges :
1. which are excluded under the General Limitations provisions ;
2. which result from any sickness or bodily injury arising out of or in the
course of an individual 's employment ;
3. cosmetic surgery.
f
-17-
SURGICAL BENEFIT
A. BENEFIT PROVISION
(7 If a Covered Person incurs necessary expense as a result of an injury or
illness which causes the person to undergo any non-cosmetic surgical proce-
dure, the Plan shall pay the Medically Necessary Usual , Reasonable and
Customary expense incurred for:
1. the services of the principal surgeon ; and/or
2. plastic and reconstructive surgery if the surgery is necessary to
correct deformities causing functional physiological difficulties
arising from illness or injury.
B. MULTIPLE AND/OR BILATERAL PROCEDURES
If two or more surgical procedures are performed at one time through the
same incision or in the same operative field, the maximum amount payable for
surgery will be the procedure for which the highest surgical benefit is pro-
vided.
In the event that two or more separate operations are performed during one
period in the operating room, the amount payable shall be the Surgical
Benefit payable for the operation performed for which the highest Surgical
Benefit is provided ; plus not over 50% of the Surgical benefits specified
for the other operation(s).
C. LIMITATIONS
1. No payment shall be made under this benefit for expenses incurred for or
on account of weight control or obesity, other than "Morbid Obesity" ; or
2. for treatment or services described under "General Limitations".
-18-
GENERAL LIMITATIONS
No benefits shall be payable under any part of this Plan with respect to:
1. any charges not Medically Necessary for diagnosis or treatment of an
illness, injury, or pregnancy; or
2. any charges for cosmetic• surgery unless due to an accident or injury
occuring while covered ; or
3. any charges for rhinoplasty, blepharoplasty or brow lift except charges for
rhinoplasties and blepharoplasties to correct a functional condition or
charges for rhinoplasty to correct a condition as a result of an acci -
dental injury; or
•
4. vaccinations, innoculations , or any charges for any examination for check-
up purposes not incidental to or necessary to diagnose an injury or
illness (except as otherwise provided for in this Plan) ; or
5. any injury or illness for which the Covered Person on whose behalf claim is
presented is not under the regular care of a Physician ; or
6. any charges for any condition , disability or expense resulting from or
sustained as a result of being engaged in an illegal occupation , commission
of or attempted commission of an assault or a felonious act ; or
7. any charges for any condition , disability or expense resulting from or
sustained as a result of war or act of war , declared or undeclared ; or
8. any charges for any condition or disability which would entitle the Covered
Person to any benefit under a Worker' s Compensation Act or similar legisla-
tion or which is due to injury or sickness arising out of or in the course
of any occupation or employment for wage or profit ; or
9. hearing aids , batteries or repairs ; or
10. any charges for professional services performed by a person who ordinarily
resides in the Covered Person ' s household or who is related to the Covered
Person as a spouse , parent , child, brother, sister , whether such rela-
tionship is by blood or exists in law; or
11. charges for instruction or activities for weight reduction, weight control ,
or physical fitness even if the services are performed or prescribed by a
Physician ; or
12. any charges for artificial insemination ; or reversal of vasectomies , or
reversal of tubal ligation ; or
13. any charges for eye glasses , correction of vision , fitting of glasses or
eye examinations ; or
14. any charges for air conditioners , purifiers , dehumidifiers , corrective
shoes , heating pads , hot water bottles , and other clothing and equipment
which is not solely for medical purposes ; or
-19-
15. any charges for special education , counseling, or care for learning de-
ficiencies or behavioral problems , whether or not associated with a mani -
fest mental disorder or other disturbance ; or
16. any charges for routine health examinations , multiphasic screening tests ,
and physician checkups not associated with any disease , injury or condition
requiring professional service or treatment (except as otherwise provided
for in this Plan) ; or
17. travel expenses of a Physician attending a Covered Person , or travel ex-
penses of a Covered Person , although recommended by a Physician ; or
18. any charges for preparing medical reports or itemized bills ; or
19. non-medical expenses such as training , educational instructions or edu-
cational materials , even if they are performed or prescribed by Physician ;
or
20. services or supplies for which there is no legal obligation to pay, or
charges which would not be made but for the availability of benefits under
this Plan ; or
21. any expenses which exceed the usual , customary and reasonable expenses for
the medical care rendered; or
22. vitamins and/or nutritional supplements ; or
23. acupuncture administered by other than an M. D. or D.O. ; or
'� 24. any charges related to custodial care, sanitarium care , or rest cares ; or
25. treatment not prescribed or recommended by a Physician ; or
26. hospitalization charges for dental treatment. However, the hospital charges
will be covered if the patient has another medical condition which requires
that dental treatment be provided on an inpatient basis and the Medical
Necessity of hospitalization is certified by a Physician ; or
27. obstetrical care for a dependent other than the spouse of an enrolled
employee or the female employee ; or
28. charges for mailing or sales tax ; or
29. medical expenses for equipment , supplies , procedures or treatments which
are experimental in nature or which have not been approved by the Food and
Drug Administration or the appropriate authorizing agency; or
30. treatment of (a) weak, strained , flat , unstable or unbalanced feet , metetar-
salgia or bunions , except open cutting operations , (b) corns , calluses or
toenails , except the removal of nail roots and necessary services in the
treatment of metabolic or peripheral -vascular disease ; or
-20-
31. expenses in connection with drug abuse , drug addiction , alcoholism, or ner-
vous and mental conditions except where specifically noted herein ; or
r 32. treatment of periodontal or periapical disease or any condition (other than
a malignant tumor) involving teeth, surrounding tissue or structure.
However, this exclusion does not apply to the benefits for dental treatment
described under the "Supplemental Accident Expenses" Section ; or
33. Chiropractic Maintenance , Palative or Excessive Care ; or
34. any expenses resulting from intentional self-inflicted injury or attempted
intentional self-destruction while sane or insane.
35. any expenses related to treatment of temporomandibular joint disfunction.
-21-
HOW TO FILE A CLAIM
Er
Claim forms can be obtained from the Personnel Office, or by calling or writing
James Benefits , 3895 Upham Street , #100, Wheat Ridge, Colorado 80034-0987, (303)
423-2400. The Employee Statement on the top of the claim form must be completed
in FULL and signed by the employee. Itemized bills (hospital , doctor anesthe-
siologist , laboratory, prescriptions , etc. ) should he attached to the claim
form, and the Attending Physician Statement on the bottom of the claim form
should be completed by the appropriate Physician unless ALL necessary infor-
mation is included on the Physician ' s own form. The completed claim form and
the attached bills should be sent to:
Weld County
c/o James Benefits
P.O. Box 987
Wheat Ridge, Colorado 80034-0987
Identification cards and claim forms are available for Plan participants from
the Personnel Office of Weld County.
-22-
COORDINATION OF BENEFITS
A. APPLICATION
If any individual covered under this Plan is also covered under other plans ,
the benefits payable under this Plan will be coordinated with benefits
payable under all other plans. Coordination will apply in determining the .
benefits payable with respect to an individual for any Claim Determination
Period if, for the Allowable Expenses incurred during that period, the sum
of the following would exceed those Allowable Expenses :
1. the benefits that would be payable under this Plan in the absence of
coordination , and
2. the benefits that would be payable under all other plans in the absence
of provisions for coordination in those plans.
Except as provided in the following paragraph , when Coordination of Benefits
applies to the benefits payable with respect to an individual for Claim
Determination Period, the benefits that would he payable for Allowable
Expenses incurred during that period under this Plan in the absence of
Coordination of Benefits will be reduced to the extent necessary so the sum
of those reduced benefits and all the benefits payable for those Allowable
Expenses under all other plans will not exceed the total of those Allowable
Expenses . Benefits payable under all other plans include the benefits that
would have been payable had claim been properly made for them.
If, in coordinating the benefits of this Plan with those of another plan,
I the rules set forth in the following paragraph would require this Plan to
determine its benefits before the other plan and the other plan which con-
tains a provision coordinating its benefits •pith those of this Plan would,
according to its rules , determine its benefits after the benefits of this
Plan have been determined, then the benefits of that other plan will be
ignored for the purposes of determining the benefits of this Plan.
B. ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination are:
1. The benefits of a plan which covers the individual for whom claim is
made other than as a Dependent will be determined before the benefits of
a plan which covers that individual as a Dependent.
2. The benefits of a plan which covers the individual for whom claim is
made as a Dependent of a male will be determined before the benefits of
a plan which covers that individual as a Dependent of a female.
However, for a dependent child of a divorced couple , the coverage of the
parent who has custody of the child will be determined before the bene-
fits of the other parent are determined (unless stipulated otherwise by
a court decree).
-23-
•
3. When Rules 1 and 2 do not establish an order of benefit determination ,
the benefits of a plan which has covered the individual for whom claim
is made for the longer period of time will be determined before the
T benefits of a plan which has covered the individual the shorter period
of time.
When Coordination of Benefits operates to reduce the total amount of benefits
otherwise payable during any Claim Determination Period with respect to an
individual covered under this Plan , each benefit that would be payable in the
absence of Coordination of Benefits , will be reduced proportionately, and the
reduced amount will be charged against any applicable benefit limit of this
Plan.
C. DEFINITIONS APPLICABLE TO THIS PROVISION
1. Plan
The term "Plan" includes the following plans under which a person is
entitled to receive or received benefits or services for or by reason of
medical or dental treatment.
a. Group Plans , insured or self-funded ; group , blanket , or franchise
insurance coverage; group hospital or medical service plans , and
other group pre-payment coverage ; any coverage under labor manage-
ment trusted plans , union welfare plans , employer organization
plans , or employee benefit organization plans.
b. The "Medicare" program, including Part A and Part B, established by
Title XVIII of the Social Security Act. A person shall be con-
sidered to be entitled to all of the coverage provided by Medicare
on and after the earliest date the person would have become so
entitled if the person had promptly submitted all applications and
proofs required for such coverage. A person who is entitled to the
coverage provided by Medicare will be considered entitled to receive
benefits , whether or not application for such coverage or benefits
has been made. It shall be deemed that any disabled person eli -
gible for Medicare benefits or any individual age 65 or over shall
be entitled to Medicare.
NOTE: Medicare benefits will be considered as secondary payments
for any eligible individual between the ages of 65 through age 69
wishing to be covered by this plan.
c. Any coverage required or provided by any statute , including any no-
fault automobile insurance provided or required by statute and/or
any automobile medical insurance.
2. Allowable Expense
Means any Usual , Reasonable and Customary item of expense at least a
portion of which is covered under at least one of the plans covering the
individual for whom claim is made. When a plan provides benefits in the
-24-
form of services rather than cash payments , the reasonable cash value of
each service rendered will be considered to be both an Allowable Expense
and a benefit paid.
t
3. Claim Determination Period
The term "Claim Determination Period" means a period commencing with any
January 1 and ending at twelve o'clock (12:00) midnight on the next suc-
ceeding December 31, or that portion of such period during which the
person on whose expenses claim is based has been covered under this
plan.
D. RELEASE OF INFORMATION
For the purposes of determining the applicability of and implementing the
terms of the above provisions of this Plan or any similar provision of
another plan , the Contract Administrator may, without consent of or notice to
any individual , release to or obtain from any other insurance company or
other organization or individual any information , concerning any individual ,
which the Contract Administrator considers to be necessary for those pur-
poses . Any individual claiming benefits under this Plan will furnish to the
Contract Administrator the information that may be necessary to implement
the above provisions.
E. PAYMENTS
Whenever payments which should have been made under this Plan in accordance
with the above provisions have been made under any other plans , the Contract
Administrator will have the right , exercisable alone and in its sole discre-
tion to pay to any organization making those payments any amounts it deter-
mines to be warranted in order to satisfy the intent of the Coordination of
Benefits Provisions. Amounts paid in this manner will be considered to be
benefits paid under this Plan ; and to the extent of these payments , the
Employer will be fully discharged from liability under this Plan.
F. CLAIMS PAYMENTS MADE IN ERROR
If payments in excess of the correct amount due are made , the Plan may
recover all excess amounts paid. Recovery will be made by reducing or
suspending future plan payments, or by requiring the Covered Person to pay
back the overpayment in full , or in installments , until the overpayment is
recovered.
G. RECOVERY AND SUBROGATION
Whenever payments have been made by the Contract Administrator in excess of
the maximum amount of payment necessary to satisfy the intent of the
Coordination of Benefit provisions , the Contract Administrator will have the
right to recover excess payment from any individuals , insurance companies or
other organizations .
-25-
In the event of payment in part or in full by this Plan of any expense
•
incurred for hospital , surgical , medical , or dental services , and medical
supplies for the benefit of an Eligible Participant or an Eligible
Participant 's dependent , this Plan shall be subrogated to the extent of the
amount of such payment to all the rights , powers, privileges and remedies ,
of the Eligible Participant or the Eligible Participant ' s dependent against
any person , firm, corporation , organization , plan or other entity regarding
the payment of such expense.
H. LEGAL ACTIONS
No action at law or in equity shall be brought to recover on the policy
prior to the expiration of 60 days after written proof of loss has been fur-
nished in accordance with the requirements of the Plan. No such action
shall be brought after the expiration of three years after the time written
proof of loss is required to be furnished.
I. PROOFS OF LOSS/TIMELY SUBMISSION OF CLAIMS
Written proof of loss must be furnished to James Benefits , in case of claim
for loss for which the policy provides any payment , within 90 days after the
date of such loss. Failure to furnish such proof within the time required
shall not invalidate nor reduce any claim if it was not reasonably possible
to give proof within such time , provided such proof is furnished as soon as
reasonably possible ; and in no event, except in the absence of legal capa-
city of the claimant , later than one year from the time proof is otherwise
required. Under no circumstances will a claim be honored for payment beyond
90 days following the date coverage terminates.
•
-26-
` f .
•
COMMON LAW SPOUSE
t Coverage is provided for a common-law spouse, as defined by the courts , in
accordance with the laws of the State of Colorado. The requirements which must
be met for a relationship to gain recognition as a Common-Law Marriage are coha-
bitation and general reputation as married. Both factors must be present. Mere
cohabitation is not sufficient. General reputation as to marital relation has
been defined by the courts to mean "the understanding among neighbors and
acquaintances with whom the parties associate in their daily lives that they are
living together as husband and wife, and not in meretricious intercourse".
(Citations omitted ) To establish the presumption of marriage by cohabitation
and repute there must be presented clear, consistent , convincing and positive
evidence. The sorts of things the courts in Colorado have relied upon are:
1. What the parties call themselves in introductions , "my wife, Betty
rather than "my girlfriend, Betty Maiden name" :
2. How each fill out forms such as credit or employment applications , i .e.
checking the block marked married or the one marked single , and the name used
by the woman. ;
3. Whether they rent their apartment or home as Mr. and Mrs. Smith;
4. Presence of joint bank accounts in a married name (joint bank account where
woman uses her family name was held to go against the presumption of
marriage relationship).
r If such evidence is present and the couple are holding themselves out as husband
and wife , they are entitled to the benefits and privileges of any other married
couple.
FACILITY OF PAYMENT
If, in the opinion of the Contract Administrator , a valid release cannot be ren-
dered for the payment of any benefit payable under this Plan, the Contract
Administrator may, at its option , make such payment to the individual or indivi-
duals as have , in their opinion , assumed the care and principal support of the
Covered Person and are , therefore , equitably entitled thereto. In the event of
the death of the Covered Person prior to such time as all benefit payments due
him/her have been made, the Plan Administrator may, at its sole discretion and
option , honor benefit assignments, if any, made prior to the death of such
Covered Person.
Any payment made by the Plan in accordance with the above provision shall fully
discharge the Plan to the extent of such payment.
-27-
t .
PROCESS IN CASE OF DISPUTED CLAIM
If a Covered Employee has reason to believe a claim has not been settled pro-
f- perly, or a claim has been improperly denied, the following process applies :
1. Contact the Contract Administrator in writing to ask for a second review.
The claim will be reviewed by the Contract Administrator and the Plan
Administrator's consultant servicing the account. If the result of this
review is not satisfactory, then:
2. Request a review in writing from the Director of Personnel of Weld County
stating in clear and concise terms the reason for disagreement with the
handling of the claim. This request must be made within sixty (60) days
after receipt of a declination letter from the Contract Administrator
(James Benefits). Upon receipt of the request , the file will be reviewed
and the results of the review will be furnished to the Covered Employee,
along with copies of pertinent Plan Documents upon which this declination
is based. If the Covered Employee still finds the claim is improperly
denied per the Plan Documents , he/she has a legal right to take what
appropriate action he/she believes is necessary.
r
-28-
CONVERSION PRIVILEGE
( Any Covered Person , within thirty-one days after the date health benefits ter-
minate because of termination of employment or because of membership in a class
or classes eligible for such coverage, shall be entitled to have issued to
him/her, without evidence of insurability, an individual policy of health
insurance provided written application therefor and payment of the first premium
thereon is made to the insurance company within said thirty-one days. Any such
individual policy issued shall cover:
a. the Person , if the health benefits under this Plan covered the Person
only; or
b. the Person and his/her Dependents, if the health benefits under this
Plan covered both the Person and the Person ' s dependents ;
and shall become effective on the day immediately following the date of ter-
mination of coverage under this Plan. The form of this individual policy,
the coverage thereunder and all other terms and conditions thereof shall be such
as is then provided by the insuring company with respect to insurance issued
pursuant to an application made in accordance with these provisions.
* If a Covered Person ' s health coverage under this Plan with respect to a
Dependent spouse is terminated because of the death of the Person , such spouse
shall be entitled to have issued to him/her an individual policy of health
insurance in the same manner and subject to the same conditions as provided for
the Covered Person.
If a Covered Person ' s health coverage under this Plan with respect to a
Dependent child is terminated because of the child 's marriage or attainment of
the maximum age specified in this Plan for Dependent children , such child shall
be entitled to an individual policy of health insurance in the same manner and
subject to the same conditions as provided for the Covered Person.
THE PROVISIONS OF THIS SECTION SHALL NOT BE APPLICABLE TO ANY INDIVIDUAL ON AND
AFTER THE DATE THE COVERED PERSON BECOMES AN ELIGIBLE INDIVIDUAL UNDER TITLE
XVIII OF THE SOCIAL SECURITY ACT AS AMENDED (MEDICARE) , OR WOULD HAVE BECOME AN
ELIGIBLE INDIVIDUAL UNDER SUCH LAW HAD TIMELY APPLICATION BEEN MADE.
* The Conversion Privilege described herein shall also be applicable to a
spouse who ceases to be a Dependent due to legal separation or legal dissolu-
tion of marriage.
_2o-
N_
I � .
r ? q
K 4K lie effective date of this Plan Document is January 1, 1983.
C .. . .
"ems
IT IS AGREED gY tablleCandTwillabte thhee basis for therovisions tadministrationained in this Pofnsaid
.. • Document
er are acceptable
.. Employer' s Employee Benefit Program described herein.
SIGNED AT Greeley, Colorado
Thi s i S+-h day of
December , 1982.
WITNESS:
U il
_mac l�-.�'=_�.Tc.� ='` G:✓�i,
`/// v` 4-- - -. �t_eCount', Ccarnissioners
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r By
me
1
-30-
IT
AMENDMENT NO. I
1-to
THE MASTER PLAN DOCUMENT
of
WELD COUNTY EMPLOYEE BENEFIT FUND
Effective date of this amendment: May 1 , 1983
In addition to amending our Plan Document, request is hereby made to the -
Plan Administrator to administer our Plan according to the following amend(s)
to our Master Plan Document.
PAGE 21 (GENERAL LIMITATIONS)
The existing paragraph is hereby replaced in its entirety as follows:
32. treatment of periodontal or periapical disease or any
condition (other than a malignant tumor or surgical removal
of bony impacted teeth) involving teeth surrounding
tissue or structure. However, this exclusion does
r not apply to the benefits for dental treatment described
under the "Supplemental Accident Expenses" Section; or
IT IS AGREED BY WELD COUNTY that the provisions contained in this Plan
Document are acceptable and will be the basis for the administration of said
Employer's Employee Benefit Program described herein.
SIGNED AT (Zreelpy . ro This 20th day of
_dame _— — , 1983.
WITNESS:
CAAIAffitrjzni
Title
•
AMENDMENT NO. II
to the Health Plan Document of the
WELD COUNTY EMPLOYEE BENEFIT FUND
The Health Plan Document of the Weld County Employee Benefit Fund is hereby
amended, effective August 1, 1983, as follows :
Page 23 - The following paragraph( s) is hereby added to the following:
COORDINATION OF BENEFITS
B . ORDER OF BENEFIT DETERMINATION
4. The benefits of this plan will be the primary plan for those active
employees ( and their dependents) until the covered person reaches age
70 and who have elected to participate in this plan. For those who are
eligible for Medicare, any unpaid charges under this plan should be sub-
mitted to Medicare for payment. -
Enrolled, active employees age 70 or older are required to submit claims
to Medicare as the primary plan.
Page 4 - The following paragraph replaces the existing paragraph in its
entirety:
A. GENERAL DEFINITIONS
1. Age Discrimination - All active employees age 65 through 69 and their
covered spouses age 65 through age 69 are entitled to the same and/or
equal benefits they had prior to age 65. Medicare is the primary
carrier on their 70th birthday, as required under Section 116, Tax
Equity and Fiscal Responsibility Act.
Weld County hereby states that the intent of this amendment is to satisfy the
requirements of Section 4(g) (1) of the Age Discrimination in Employment Act of
1967 (added by Section 116(a) of the Tax Equity and Fiscal Responsibility Act of
1982) . It is intended that this amendment is to be interpreted in a manner that
will accomplish this purpose.
IT IS AGREED BY WELD COUNTY that the provisions contained in the Plan
Document and Amendment No. II thereto are acceptable and will be the basis for
the administration of said Employer' s Employee Benefit Program described herein.
SIGNED at , Colorado, this day of
1983.
WELD COUNTY
Witness : By
' ryL _ wv ; ✓:c :w Title
Am1/10-1
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